When I walk through my hospital’s emergency department, I’m sometimes overwhelmed by the number of people languishing there as they wait for help with a mental health issue, like the woman clutching her chest as if she’s having a heart attack but is really suffering from a panic attack. It’s her third time here in a week.

She is just one of the hundreds of patients who will be admitted this year to my emergency department in the Mat-Su Regional Medical Center in Palmer, Alaska, experiencing psychiatric emergencies.

Many stay in the emergency department for hours; some even stay there for a few days. The practice, called psychiatric boarding, occurs when an individual with a mental health condition is kept in an emergency department because no appropriate mental health care is available. It’s rampant around the country.

Millions of Americans with mental health issues are not getting the care they need. It’s a crisis so profound that it is overwhelming emergency departments and the entire health care system. The causes? Too few outpatient resources and inpatient treatment options for mental health issues; separate systems for treating mental health and physical health; and a shortage of specialists able to respond to patients in the midst of mental health crises, to name just a few.

I believe hospitals can curb this trend by doing a few key things, beginning with improved collaboration.

The statistics are staggering: Nearly 1 in 5 U.S. adults — about 44 million — experiences mental illness in a given year, a number that is certain to increase. And it comes at a time when the demand for mental health professionals is outstripping the supply. For psychiatrists alone, a 2017 report published by the National Council for Behavioral Health estimates the shortage will be between 6,100 and 15,600 practitioners by 2025. That same report points out that lack of access to psychiatric services in hospital emergency departments is especially problematic.

In less than three weeks, on Tuesday, November 6th, Wisconsinites will go to the polls to vote in races for the U.S. Senator, Governor, 17 of Wisconsin’s 33 State Senate districts, all 99 of Wisconsin’s State Assembly districts and a variety of local elections and referenda. Between now and then, we’ll be inundated with radio and TV ads, campaign flyers (and maybe candidates) at our front doors, political “robocalls” and media reports about candidates, races, polls and predictions. ‘Tis definitely the season!

Political insiders watch political polls like hawks, hoping to glean from them predictions of election outcomes. But in 2016 we learned a powerful lesson about political polling in modern times – not one national pollster predicted victory by President Trump, either in Wisconsin or nationally. More and more, people of different demographics are moving from landlines to mobile phones increasing the difficulty of getting a representative population sample in a poll. That simple fact, along with how questions are asked, who asks the questions and a variety of other factors increase the difficulty of getting statistically accurate poll results.

For WACEP, our attention is primarily on the races for Governor, State Senate and State Assembly as the outcomes of those races can have a profound effect on health care policy making for the next two years and beyond.

The Governor’s race is the one most discussed in the state’s media. Governor Walker has served two four year terms, yet won election as Governor three times. Tony Evers, his Democratic challenger, has served as Wisconsin’s State School Superintendent, himself winning multiple statewide elections. As divided as Wisconsin’s voting population has become, and both candidates holding strong name recognition throughout the state, this race figures to be close to the end.

In the State Senate, after Democrats won two previously Republican-held seats during Spring Special elections, Republicans hold a 18-15 majority heading into November. Democrats are focusing on two key Republican seats (one in the Appleton area, one in the large rural district west of Madison) in an effort to win the majority. But Republicans see opportunities of their own to win back one of the Special Election seats in the 1st Senate District in Door/Kewaunee County, as well as a far northern seat that includes Superior, Ashland and Rice Lake.

In the State Assembly, Republicans hold a far larger 64-35 majority. To win the majority, Democrats must hold all their current seats and win 15 more. It’s a daunting challenge, and while anticipated high voter turnout in places like Democratic stronghold Dane County may have a big impact on the Governor’s race, it won’t affect Assembly races in central and northern Wisconsin.

The outcomes of these 2018 elections will come down to voter turnout for both parties – throughout the state, not simply in party stronghold areas. As you see polls being reported in the media, remember 2016. Elections aren’t won by polls or pundits, they’re won by votes – so get out and cast yours on November 6th!

Emergency physicians do not typically think of cannabis as pertinent to our typical clinical practice. This is demonstrated by the fact that ACEP has not adopted any of 14 resolutions (both in favor of and in opposition to recreational marijuana) that have been proposed in the last 10 years. On the other hand, our practice is, in some ways, is defined by the failures of the healthcare system, from chronic intractable conditions in need of a novel treatment to the unanticipated side effects of increasing exposure to a recreational substance. We may get pulled into this debate on the national level.

But what about at the state level? Marquette Law School poll done in August showed that 61 percent of Wisconsinites say marijuana should be fully legalized and regulated like alcohol while 36 percent oppose legalization. Advisory referendum questions on marijuana will be included on ballots in 16 different counties and 2 cities next month. With all of this local action, I was recently faced with the question of “What would you say to a reporter who asked what emergency physicians of Wisconsin think about marijuana?” While our state chapter of ACEP does not form individual policy apart from our national organization, it is important that our chapter reflects our local environment. I believe there are likely low-hanging fruit that would reflect commonalities among WI emergency physicians’ opinions on how we could best represent our patients in this public debate. Read below for background information on what pertinent policy exists, and then email me with how you think emergency physicians in Wisconsin should publicly regard marijuana for recreational use, medical use, research, or other!

Recreational use: Nine states and the District of Columbia have legalized recreational use of marijuana for adults over the age of 21. Twenty-two states and the District of Columbia have decriminalized small amounts of marijuana. AMA has policy on recreational use or legalization of marijuana:

Initially established in 1997 and modified several times until it was reaffirmed last year, the AMA urges legislatures to delay initiating the legalization of cannabis for recreational use until further research is completed on its consequences.

Advocates for point of sale warnings and product labeling regarding potential dangers of cannabis-based product use during pregnancy and breastfeeding.

For states that have already legalized cannabis, they should take steps to regulate it. If taxed, a substantial portion of the revenue should be used for public health purposes.

Public health based strategies, rather than incarceration, should be used to handle individuals possessing cannabis for personal use.

Supports continued educational programs on substance abuse to include marijuana

It is notable that ACEP does not have policy on legalization of recreational marijuana. This also includes a proposal last month in San Diego at ACEP18 Council to approve policy language mirroring the first AMA policy listed above. Discussion on the ACEP council floor in opposition to policies regarding recreational marijuana often centers around the idea that recreational marijuana is not within the scope of emergency medicine, although emergency physicians may have opinions on recreational marijuana as individuals.

Medical use: Thirty-one states have legalized marijuana for medicinal use. In addition, 15 other states, including Wisconsin, only allow use of low THC, high cannabidiol products for limited medical conditions such as seizure disorders.

Much of existing AMA policy about medical use of marijuana focuses on the basis of physician-patient relationship being free from interference by the government:

Cannabis products for medicinal use should be considered for approval by the FDA, not legalized through legislative, ballot, or referenda initiatives. Any FDA-approved cannabidiol medications should be regulated as other prescription products are, rather than state laws that may apply to unapproved cannabis products.

Cannabis products not approved by the FDA will have warning labels indicating such

Supports protection against federal prosecution for physicians who discuss cannabis with patients or recommend cannabis in accordance with state laws

The Wisconsin Medical Society (WMS) policy affirms the third point above, and also goes on to state that smoked marijuana should only be used for therapeutic reasons for which we have scientific data regarding safety and efficacy.

Again of note, ACEP has a noticeable lack of policy in this realm, and in fact did not adopt 3 proposed policies over the last few years, including proposal to protect the right of emergency physicians to prescribe medical marijuana and a proposal to officially take no position on the medical use of cannabis products.

Research: AMA again takes the lead in ample policy regarding research of cannabis use. They encourage public health agencies to improve data collection of effects of cannabis. The AMA and WMS have the same following policy:

Urge that marijuana’s status as a schedule I controlled substance be reviewed with the goal of facilitating the conduct of research and potential development of medicines

Call for adequate studies of cannabinoids

Urge federal agencies to fund and facilitate the conduct of research

Interestingly, although the ACEP Council voted to not approve a resolution in 2014 to specifically promote research of medical marijuana, they did just last month approve the very first ACEP resolution regarding cannabis, mirroring language of the first above AMA/WMS policy point.

Wisconsin statute includes a provision that a psychiatric bed locator be maintained as a single point of reference of psychiatric bed availability. The bed locator website was developed, and is maintained, by the Wisconsin Hospital Association. The site is meant to assist emergency departments when seeking to transfer and admit patients for psychiatric reasons.

In an effort to work with WHA to identify possible areas of improvement for the bed locator, WACEP has developed a short survey for its members regarding the site’s usage. Please take a moment to answer the survey.

You’re working a busy 12 hour shift, and a patient with chief complaint of “SI” pops up on the board. Gulp. The evaluation is uniquely straightforward: this 54 year old female has a history of depression and is having passive thoughts of suicide in a stressful time, very clearly presents with her husband for voluntary admission. No ED hold needed. You find no other medical concerns and even get her accepted at the nearest psych hospital promptly, which happens to be 50 miles away. Bingo bango, you’re on a roll!

Then comes the question of what “mode of transportation” are you going to fill out on the EMTALA form? The patient just assumes that her husband can drive her there, but your hospital has a policy that all psych transfers must go by ambulance, sticking this family with a hefty bill. Your gut is that she is extremely low risk for harm or non-adherence to the care plan during private transport. Is there merit to insisting on ambulance transfer?

We had this exact question presented to our chapter by our members. Certainly, there is a time and place when your spidey sense tells you to opt for ambulance transfer even for voluntary admissions. However, for the seemingly low risk patients, we wanted to supply our members with data who wish to have discussions with their hospital administrators if you want to pursue more flexible standards for transportation in voluntary psych transfers. See here for a seven-page legal summary concluding that the mode of transportation should be left to the judgement of the physician, done by our contracted attorney, Guy DeBeau from Axley Brynelson, LLP. It includes an interesting summary of pertinent case law, and tips for how to safely document characteristics you may have considered when assessing your patient’s level of risk for harm during transfer. It is worth pointing out that the memo does not include any examples of civil suits for harm that occurred during a similar transfers in Wisconsin, because there aren’t any such lawsuits.

For other points of discussion, WACEP has received some helpful tips from our partners in the WI Psychiatric Association. They refer to the CMS booklet on Non-Emergent Medical Transport for the “standard of care” for transportation of psychiatric patients, which comments on the difference between clinical scenarios that necessitate emergent transport and those that are non-emergent. For potential discussions of other transportation options, keep in mind non-ambulance secure transport choices as well, such as JBM, Able- Access, or Lock n Load.

Does your hospital have a policy to mandate that all patients being transferred for voluntary inpatient psychiatric care go by ambulance? Do you feel that this is appropriate, or are you looking for a change? We are interested in how we can further help with this issue in Wisconsin EDs.

Six Wisconsin ACEP members have recently been awarded the distinct designation of Fellow of the American College of Emergency Physicians (FACEP), bringing WACEP's total number of members with this status to 208. Congratulations to Wisconsin's most recent Fellows:

Joseph Humphrey, MD, FACEP

Timothy J. Lenz, MD, FACEP

Michael Mancera, MD, FACEP

Jessica N. Schmidt, MD, MPH, FACEP

Michael Thomas Steuerwald, MD, FACEP

Joseph D. Verzwyvelt, MD, FACEP

The Fellow designation speaks to a member's contributions to ACEP and highlights their commitment to emergency medicine. More than 12,000 ACEP members proudly use the prestigious FACEP designation.

The Wisconsin Chapter, ACEP Nominating Committee is now accepting nominations of any member in good standing interested in serving in WACEP leadership.

WACEP's Board of Directors meets quarterly and provides ongoing strategic oversight as the organization works to advance the effectiveness, sustainability and mission of the Chapter. Board members are expected to participate in all Board meetings, the annual conference, and various activities related to the organization's strategic priorities.

For terms of office beginning January 1, 2019, nominations are being accepted for the following positions:

Director at Large on the Board of Directors (4-year term)

Councillor to ACEP (3-year term)

President-Elect (this is a 3-year commitment, one year each as President-Elect, President and Immediate Past President)

Secretary/Treasurer (1-year term)

If you or any of your colleagues are committed to serving in a leadership capacity and being a resource for information, education, networking and advocacy, we encourage you to get involved Nominations close November 15, 2018.

Healthcare is poised to play a central role in the 2018 state and federal elections, and the results could reverberate across Wisconsin.

Democrats are hoping a blue wave will put the brakes on President Trump’s attack on the Affordable Care Act, but if Republicans retain control of Congress, it may seal the law’s fate. Meanwhile, the races for Governor and the Legislature are certain to shape the future of healthcare for years to come.

A panel of the state’s top healthcare lobbyists will analyze what’s at stake for the Badger State and preview their priorities for the coming year. Panelists:

Eric Borgerding, CEO, Wisconsin Hospital Association

​Dr. Bud Chumbley, CEO, Wisconsin Medical Society

​Stephanie Harrison, CEO, Wisconsin Primary Health Care Association

​John Sauer, CEO, LeadingAge Wisconsin

​Nancy Wenzel, CEO, Wisconsin Association of Health Plans

The event is Tuesday, September 11 at the Madison Club (11:30am – 1pm). Register here.

I’m a partner in a medium-sized democratic group, big enough to generally be sheltered from huge swings in clinical load due to any individual's personal leave or hiring of a new partner. I have EM doc friends who have mentioned that they’d have to miss out on previous commitments because of staffing changes such as those. That always felt like a far-away problem, until recently, when our group was fortunate to pick up another contract, significantly increasing the clinical load faster than any group could hire. Bottom line: I got steam rolled, drowning in work and losing contact with my “real” life. It was all voluntary by the way; in our group’s typical uber-democratic fashion, I was able to choose how many shifts I could bear for a handful of months until more docs were hired on. Just now I’m coming out on the other side as a great new group of docs recently joined our ranks, and I’m able to look back and reflect on lessons learned during my own ebb and flow of clinical work that is common for emergency physicians.

Professional Lessons

The Good - I typically work a lesser load of clinical shifts than most partners in my group due to also taking on administrative work, but had more of a typical load as of late. I felt all warmed up every time I was heading into the hospital! The usual stale cobwebs and inertia after a few days off of clinical work was never there, making the first patient encounter of a shift just as smooth as the last. Clinically I felt like a well-oiled machine and it makes me appreciate that there truly is a critical mass of patients that I personally must see on a regular basis to keep sharp. This will likely prove useful to remember as I near retirement or consider other non-clinical opportunities. Perhaps even now, clustering my shifts might be the way to go as I try to balance clinical and non-clinical duties.

The Bad - I am typically an everlasting gobstopper of empathy. I would never question the logic of a patient’s choice of ED visit versus a PCP office, or why 3 a.m. seemed like the right time to stop on in. People have their reasons. But just jack up my clinical load a bit (ok, a lot) and my shoulders started to tense with each bell of the ambo door. I knew it was taking a toll on me when I would read the triage nurse’s note and immediately internally start to question the motives of the patient I was about to see. An alarm bell went off in my head. Although I realized one could argue that this type of questioning is totally appropriate, I knew it wasn’t my typical outlook, and it was an outlook that certainly made it harder for me to love my profession everyday. Keeping my previous empathy might even be more important that having a warmed-up clinical mind, in my opinion. It has quickly returned with my now decreased clinical load.

The Ugly - see below.

Personal Lessons:

Prioritize priorities - I had it all set. My google calendar was loaded up, defending my personal life from my shifts. Workouts? Check. Sleeping? Check check. My kids were even getting scheduled so I would be sure to set aside time for them. But man, something was lost in translation. My husband and I were interacting more as the changing of the guards than anything else. Google calendar doesn’t do well providing downtime and spontaneity. Everything but the bare essentials went to the wayside. I hadn’t hung out with my sister for months. I stopped turning down invitations to meet up with friends because the invitations stopped coming after being turned down so regularly. A friend even asked me what it was like to live and breathe work. Eek! That’s not what I signed up for. We made it to the other side just fine and I’m having a great time catching up with everybody, but when there not enough slots to fit in all the priorities, something’s got to give. I don’t think I’m alone among emergency physicians who aim to work to live, rather than live to work. It’s easier than I thought to let it slip the other way.

Guilt was gone - On the lighter side, the trouble I normally have with trying to balance work with everything else was suddenly easier when work ticked up, mostly because I got very skilled at saying no to protect my time. Meeting mid-morning after a night shift? No way, Jose. PTA meeting on my night off? Sorry, not sorry. Cook dinner? I’ve prepared some exquisite Subway for the family. Outsourcing was in full force: yardwork, grocery shopping, scrubbing toilets? Buh-bye, buh-bye, buh-bye. Even now that things have slowed down again, as long as I can swing it, I’ll attempt to keep the guilt away and the outsourcing full speed. It’s amazing how the world continues to spin even though I haven’t personally balanced the school budget nor picked up a toilet brush. Nothing like a little stress on my time management to help me flex those boundaries I should always set for myself.

For those of you in smaller shops with even smaller staffs, I imagine this swing in lifestyle is your reality. Hats off to you. You likely have many more lessons to share with the rest of us. Share them! Hopefully, my lessons could better prepare or at least normalize this sort of transition for a Wisconsin EM doc who will experience something similar soon. Most importantly, it was worth it. The docs in my group are my family, and even though I might have a few more tricks up my sleeve next time, I know I’m ultimately in the right place because I’d do it all again in a heartbeat for my group and profession that I am so lucky to have.

Editor's note: Send your own lessons-learned, stories from the front, and comments to Dr. Maurer by emailing WACEP@badgerbay.co.